COVID-19 Screening Form

Have you had a fever, shortness of breath, difficulties breathing, cough, fatigue, loss of sense of taste or smell, or flu-like symptoms within the past 14 days?
Have you tested positive for COVID-19 within the past 14 days?
Have you been tested for COVID-19 and are still waiting for the results?
Are you in contact with any confirmed COVID-19 patients or persons suspected to have COVID-19, or do you live with anyone who is currently quarantined?
Have you traveled outside of Central New York?

I attest that the above information is true to my knowledge

On a mobile device, use your finger to sign in the space below. On a desktop computer, use your mouse to sign in the space below.

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